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17 Soc - Sec.rep - Ser. 788, Medicare&medicaid Gu 36,323 George Friedman v. Secretary of The Department of Health and Human Services, 819 F.2d 42, 2d Cir. (1987)
17 Soc - Sec.rep - Ser. 788, Medicare&medicaid Gu 36,323 George Friedman v. Secretary of The Department of Health and Human Services, 819 F.2d 42, 2d Cir. (1987)
17 Soc - Sec.rep - Ser. 788, Medicare&medicaid Gu 36,323 George Friedman v. Secretary of The Department of Health and Human Services, 819 F.2d 42, 2d Cir. (1987)
2d 42
Charles Robert, Robert, Huber & Lerner, Hempstead, N.Y., for plaintiffappellant.
Robin L. Greenwald, Asst. U.S. Atty. (Andrew J. Maloney, U.S. Atty. for
E.D.N.Y., Robert L. Begleiter, Asst. U.S. Atty., of counsel), for
defendant-appellee.
Before KAUFMAN, WINTER, and MAHONEY, Circuit Judges.
WINTER, Circuit Judge:
This is an appeal from Judge Korman's decision upholding the denial by the
Secretary of the Department of Health and Human Services ("Secretary") of
Medicare benefits for a portion of Friedman's hospital stay during 1982. We
initially issued a summary order affirming the judgment under our Rule 0.23,
but have since vacated that order at the government's request. We again affirm,
but on a different rationale.BACKGROUND
On April 9, 1982, the hospital notified Friedman that his stay was no longer
necessary and that he was no longer covered by Medicare. The Social Services
Department decertified Friedman for coverage as of that date and notified his
family of the decertification. The Department's notes indicate that a bed
became available at a private nursing home on April 30, but that Friedman's
family rejected it. The physicians' progress records in March and thereafter
contain the repeated notation that Friedman was "awaiting ECF" (extended care
facility). Two DMS-1 forms, filled out by a registered nurse and dated May 13
and September 9, indicated that Friedman's care should involve "skilled nursing
supervision."1 In September, New York Blue Cross ("NYBC"), the Medicare
program's fiscal intermediary, informed Friedman that no further hospital
insurance benefits would be allowed for care after April 12, 1982. Friedman
remained in the hospital until October 6, 1982.
correct.
7
Dr. Texon had not examined Friedman personally but had reviewed his hospital
records and medical history. Dr. Texon concluded that Friedman required
neither acute hospital care nor skilled nursing care from April 13 to October 6,
1982. He based this conclusion on the facts that after April 12, Friedman's
condition was stable, he no longer needed intravenous medication, and his
treatment "consisted of just repeating orders at intervals as required."
According to Dr. Texon, Friedman "needed care, but not skilled nursing care."
The ALJ denied Medicare benefits as of April 13, 1982, on the ground that
Friedman did not require or receive skilled nursing care as of that date. The
ALJ's ruling became the final decision of the Secretary when it was approved
by the Appeals Council on October 31, 1983. The claimant then sought review
of the Secretary's decision in the Eastern District of New York pursuant to 42
U.S.C. Secs. 405(g) and 1395ff(b). The district judge dismissed the complaint
in an oral decision from the bench.
DISCUSSION
A. The Requirement of Physician's Certification
10
11
In the district court, the Secretary argued that the denial of benefits should be
upheld because Mr. Friedman had not produced a physician's certification of
need for the medical services as required by 42 U.S.C. Sec. 1395f(a)(2) (Supp.
III 1985). The district judge agreed and upheld the denial of benefits principally
on that ground. The Secretary repeated the argument on appeal to this court,
and we originally affirmed the ruling below by an unpublished order that relied
upon that contention.
12
The United States Attorney's Office subsequently informed us, however, that
the Secretary had erred in his reading of the statute and was thus modifying his
argument in this and similar cases. The Secretary now maintains that the
certification requirement of 42 U.S.C. Sec. 1395f(a)(2) relates only to payment
for services rendered under the Medicare program, not to coverage for such
services. The Secretary notes that coverage and payment are treated as two
separate inquiries: first, the Secretary determines whether the individual and the
services involved are covered by Medicare, and, second, if coverage exists, the
Secretary determines whether the other requirements for payment to the
provider have been met. Moreover, once coverage is established, the provider
of services, not the patient, is responsible for obtaining the necessary
physicians' certifications, 42 C.F.R. Sec. 405.1625(b) (1986), and for bearing
the risk of nonpayment if such certifications are unavailable. 42 C.F.R. Sec.
489.21(b)(1) and 489.40(b) (1986).
13
We agree with the Secretary's interpretation of the statute. Because the claimant
in the instant case disputes the Secretary's determination concerning coverage,
the certification requirement is irrelevant. Accordingly, we vacated our earlier
order.
15
It is conceded that after April 12, 1982, Friedman did not receive care
reimbursable under the Medicare provisions covering inpatient hospital care, 42
U.S.C. Sec. 1395d(a)(1). Friedman contends, however, that the services
received during this period are reimbursable under the provisions covering
extended care services, 42 U.S.C. Sec. 1395d(a)(2)(A), which provide for up to
100 days of post-hospital extended care services during any spell of illness.
Although post-hospital extended care services ordinarily consist of those
services furnished to an individual after transfer from a hospital to an SNF, see
42 U.S.C. Sec. 1395x(h) and (i), a patient who needs skilled nursing care and
remains in the hospital solely because no SNF bed is available may be
reimbursed for that care. 42 C.F.R. Sec. 405.1627(b). See Monmouth Medical
Center v. Harris, 646 F.2d 74, 80 & n. 10 (3d Cir.1981). Friedman thus argues
that from April 13 to October 6, 1982, he was receiving skilled nursing care
and was awaiting discharge to a skilled nursing facility. The government
counters that during this period Friedman did not need skilled care and that the
care he received was merely custodial.3 See 42 U.S.C. Secs. 1395y(a)(1)(A) (no
payment may be made for any expenses "not reasonable and necessary for the
diagnosis or treatment of illness or injury") and (a)(9) (no payment may be
made for "custodial care").
16
Custodial care is not defined in the Social Security Act, and the regulations
merely provide illustrations of services that do not fall within the terms. 42
C.F.R. Sec. 409.33(d)(1986). The regulations do state that "[c]ustodial care is
any care that does not meet the requirements for coverage as post hospital SNF
care." 42 C.F.R. Sec. 405.310(g)(1986). Posthospital SNF care is defined as
services that, inter alia, (1) are ordered by a physician, (2) require the skills of
technical or professional personnel, and (3) are necessary on a daily basis. 42
C.F.R. Sec. 409.31. See also 42 C.F.R. Sec. 409.33 (setting forth examples of
skilled nursing services).
17
18
In rendering his decision, the ALJ stated that he had considered all of the
evidence in the record, and he detailed those portions on which he relied. We
conclude that substantial evidence supports his decision. The testimony of Dr.
Texon provided a detailed explanation of why Friedman's overall condition and
needs were such that he was not receiving and did not need skilled nursing
services. This conclusion is consistent with the statements in the nurses' notes,
the physicians' progress records and order sheets, and the URC reports. Thus, "
[t]his is not a case in which the ALJ and reviewing physician reached a
decision contrary to the uncontroverted medical testimony, or unsupported by
other adequate acceptable evidence." Warncke v. Harris, 619 F.2d 412, 416
(5th Cir.1980).
19
20
The claimant's other evidence was wholly conclusory except for Batkin's
testimony that Friedman's doctor said Friedman "belonged in a skilled nursing
home and to send him back home would, literally, destroy and kill Mrs.
Friedman." Even if we assume that the treating physician rule developed in
Social Security disability cases, see Havas v. Bowen, 804 F.2d 783, 785-87 (2d
Cir.1986); Schisler v. Heckler, 787 F.2d 76, 81-85 (2d Cir.1986), applies in
Medicare reimbursement cases, compare Gartmann, 633 F. Supp. at 680
(stating that treating physician rule "may well apply with even greater force in
the context of Medicare reimbursement") with Rendzio, 403 F. Supp. at 919
(noting that "persuasive authority" advises against extending treating physician
rule to Medicare determinations), there is insufficient evidence in the instant
case to put that rule in issue. First, the quoted statement is ambiguous as to
whether it weighs skilled nursing services against professional custodial care or
merely against home care. Second, the treating physician rule does not come
into play absent a more detailed identification of the physician to whom the
conclusion is attributed and a description of his or her role as a treating
physician. The record reflects that Friedman was a "regular patient" of one Dr.
Maron. It also reflects that two other doctors examined Friedman for various
reasons and at various times while he was in the hospital. Because Batkin
testified that he would remember the doctor's name if he saw it, we may
presume that it was not that of any of the doctors, including Dr. Maron,
mentioned in the exhibits, all of which were available at the hearing and had
been examined by Batkin's attorney. Batkin's testimony therefore is insufficient
to put the treating physician rule in issue.
21
The decision of the district court upholding the Secretary's denial of benefits is
affirmed.
The DMS-1 form is not related to the Medicare program but is used by
hospitals in connection with New York's state-administered Medicaid program.
See Blum v. Yaretsky, 457 U.S. 991, 1006-08, 102 S.Ct. 2777, 2786-87, 73
L.Ed.2d 534 (1982); id. at 1019-27 102 S.Ct. at 2793-97 (Brennan, J.,
dissenting) (discussing structure and purpose of DMS-1 form)
The government also asserts that benefits were properly denied because
Friedman failed to meet the "bed is not available" requirement of 42 C.F.R. Sec.
405.1627(b), due to his refusal to accept placement in a private nursing home in
April 1982. Because we affirm on the ground that Friedman received only
custodial care, we do not address this issue
The claimant also maintains that the predictor scores of 326 points on the two
DMS-1 forms support the argument for Medicare coverage. Under New York
regulations, a predictor score of 180 or more signifies a Medicaid patient's need
for a skilled nursing facility, see 10 N.Y.C.R.R. Sec. 415(a)(2), rather than an
intermediate care facility, called "health-related facilities," see 10 N.Y.C.R.R.
Sec. 420.1(a). See Blum v. Yaretsky, 457 U.S. at 994, 102 S.Ct. at 2780; id. at
1021, 102 S.Ct. at 2794 (Brennan J., dissenting). Yet these scores are not
directly pertinent to the Medicare program, much less conclusive. As the
Supreme Court acknowledged in Blum v. Yaretsky, "the physicians, and not the
forms, make the decision about whether the patient's care is medically
necessary." 457 U.S. at 1006, 102 S.Ct. at 2787. Moreover, because
intermediate care facilities often provide a low level of services, the scores are
weighted in such a way that patients who require aid in activities such as
walking, eating, or dressing may qualify for SNF placement even though they
may not require skilled nursing care on a daily basis. See O'Keefe v. Bowen,
643 F.Supp. 523 (E.D.N.Y.1986)